AccountId: 011433970860
ContactId: 4a5a11b0-2f78-44c0-bd13-58a999dcbdcf
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 658200 ms
Total Talk Time (AGENT): 252657 ms
Total Talk Time (CUSTOMER): 230846 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/05/4a5a11b0-2f78-44c0-bd13-58a999dcbdcf_20250505T14:44_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi I have a question um I had submitted some paperwork, um, for a claim and we were paid out on what I had submitted which was for the facility and the anesthesiologist, um, but I forgot to initially include the surgeon's bill which I did and it was processed but it didn't pay anything out so I was wanting to see why that was.
[AGENT][POSITIVE] OK. Oh well, I can definitely help you with your claim status. So, may I have your name and a good contact number just in case we're disconnected?
[CUSTOMER][NEUTRAL] My name is [PII] and my phone number is [PII].
[AGENT][NEUTRAL] Thank you, Miss [PII]. May I have your policy number?
[CUSTOMER][NEUTRAL] Yes it is.
[CUSTOMER][NEUTRAL] 261-663-9
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And I have your policy here. I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] 10977 and [PII] my email.
[CUSTOMER][NEUTRAL] Is [PII].
[AGENT][NEUTRAL] Thank you for that. And all the information provided is a verification of benefits, not a guarantee of payment, and is a claim for you, your spouse, or one of your dependents?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] My husband.
[AGENT][NEUTRAL] OK, let me go to your husband.
[AGENT][NEUTRAL] And it's the claim number ending in 6857?
[CUSTOMER][NEUTRAL] Uh, yes, mhm.
[AGENT][NEUTRAL] OK, here it is. Hold on one second. I'm just waiting for it to come up.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK. So,
[AGENT][NEUTRAL] Between the two claims, um, both of the dates of service are on [PII]. So this first claim paid out towards the surgery. So the second claim is just saying of the two we paid towards the most expensive, um, surgery, sorry.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEGATIVE] I'm confused so.
[CUSTOMER][NEUTRAL] If we are to submit the surgeons, anesthesiologist, and the facility, correct?
[CUSTOMER][NEUTRAL] That those are the three that we.
[CUSTOMER][NEUTRAL] Can submit for um for a claim um why wouldn't.
[CUSTOMER][NEGATIVE] So we don't get paid for we don't get a portion back for each it's I I'm confused.
[AGENT][NEUTRAL] Let me pull up your benefits so I can see everything. Hold on one second.
[AGENT][NEUTRAL] OK. So for your surgical and anesthesia benefit, the policy would pay for
[AGENT][NEUTRAL] The surgery up to $10,000 and for the anesthesia benefit it's 20%, 25% of however much was paid towards the surgery. So this surgery,
[AGENT][NEUTRAL] The charge was $8,138 and $600 was applied to that balance. So because we applied the $600 to that balance, when the next surgery came in for the same day, we couldn't pay out on it.
[CUSTOMER][NEUTRAL] Well, I mean it was the same, it's the same surgery though.
[CUSTOMER][NEUTRAL] I just didn't, I just forgot to add the surgeon's bill.
[CUSTOMER][NEUTRAL] Because the first, the claim number 720.
[CUSTOMER][NEUTRAL] That was for the facility and the anesthesiologist.
[CUSTOMER][NEUTRAL] So if the 6, I, I was told that you, we.
[AGENT][NEUTRAL] So it's not per surgery. This is that still goes to
[CUSTOMER][NEUTRAL] I know this is not per surgery.
[AGENT][NEUTRAL] So the 600.
[CUSTOMER][NEUTRAL] Yeah, I'm not saying he's had multiple.
[CUSTOMER][NEUTRAL] This is all one surgery.
[AGENT][NEUTRAL] And 600 was applied to it. So when we received the other claim, we couldn't apply because we already, it's still, whether it was one surgery or multiple, it's still [PII], and we applied to a surgery on that day. So we can't even though it's the same surgery, different bills is the same day and the 600 had already been applied.
[CUSTOMER][NEUTRAL] Yeah I understand you're not understanding what I'm trying to say. What I'm asking is I was told that in in the past like we submit.
[CUSTOMER][NEUTRAL] We can submit our.
[CUSTOMER][NEUTRAL] Surgeon's bill, itemized bill.
[CUSTOMER][NEUTRAL] The facility bill.
[CUSTOMER][NEUTRAL] And the anesthesiologist bill.
[CUSTOMER][POSITIVE] And we would get in a portion back or percentage back for each of those.
[CUSTOMER][NEUTRAL] But from what you're telling me and I just need clarification is that 600, that's just for the facility that is not what we were that's not the whole bill we still have the anesthesiologist bill and the surgeon's bill.
[CUSTOMER][NEUTRAL] So how, so why do we need to submit a surgeon and anesthesia bill if we're not getting any portion percentage back on it?
[CUSTOMER][NEGATIVE] Because the $600 you're telling me is just for the hospital bill that 8138, that's just the hospital bill that's not the surgeon or the anesthesiologist.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I separated them all out.
[AGENT][NEUTRAL] So what I can do, um, if you like, I can get a um claims examiner on the line to see if they need to reprocess this or if it's um corrected from the way it's here, we can only, and I'm sorry that they were that they told you that some of the, part of that is true, it is.
[AGENT][NEUTRAL] Sounds like it's a lot mixed in one. So yes, we do apply because you do have the anesthesia benefit and you do have the surgery benefit. So yes, we do apply, but that $600 was for that day, but I can get an examiner uh if you'd like just to go over it more.
[CUSTOMER][NEUTRAL] Yes, because you guys, yes, because how could you apply, how could that be the total when you never had the surgeon's bill to take into consideration when that $600 was paid out, you, you, you all did not have the surgeon's bill.
[AGENT][NEUTRAL] OK, and I can let the examiner know that and if they need to reprocess, they definitely can. I just don't want to say yes or no because I don't examine and I, I don't know for sure. All I know is what I see, um, but I can definitely get more direction for you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] That would be great thank you.
[AGENT][NEUTRAL] You're welcome. And before I do that, Ms. [PII], was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] No, that's it.
[AGENT][NEUTRAL] All right. Well, thank you for calling APL and hold on one moment, OK?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring
[CUSTOMER][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], this is [PII] on the care team. How are you doing?
[CUSTOMER][POSITIVE] I'm good. How are you?
[AGENT][NEUTRAL] I'm doing good. I have an insured um on the other line. She wants to talk about her claim. Um, the policy number is
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 261
[AGENT][NEUTRAL] 663 9.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's part two.
[AGENT][NEUTRAL] Um, both of the claims there it's the same date of service, but she forgot to submit the surgical bill, which is that last one there. We applied, we paid the 1st 1 $600. She's wanted to know how did we come up with that because we didn't have the surgical bill at the time and is there anything applied to anesthesia? I let her know these are all the same codes and we applied it to the first claim, but she
[AGENT][NEUTRAL] wants to know why we didn't pay anything to anesthesia and how we came up with the amount if we didn't have the surgical bill.
[CUSTOMER][NEUTRAL] One second, let me pull it up.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So these are the surgery center charges, but you can send her on over.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Hello, Ms. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you so much for holding. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Good morning Ms. [PII]. Thanks for calling APL. How are you today?
[CUSTOMER][POSITIVE] I'm good how are you? I'm doing well thanks for asking.
[CUSTOMER][NEUTRAL] OK, she stated, did you have a question about your claim? I did. OK, so maybe I'm gonna write this down so can you explain to me so.
[CUSTOMER][NEUTRAL] Um, what?